Pre-Consultation Form
Item ID
Name
*
First Name
Last Name
Today's Date
*
-
Month
-
Day
Year
Date
Date of Birth
-
Month
-
Day
Year
Date
Street Address
City
State
Postal / Zip Code
Phone
Please enter a valid phone number.
Email
*
example@example.com
Are you currently married to the other party?
*
Yes
No
Date of Marriage
*
-
Month
-
Day
Year
Date
Is your marriage a covenant marriage?
*
Yes
No
I'm not sure
Children
Name and age of children common to both parties.
Name (child 1)
Age (child 1)
Name (child 2)
Age (child 2)
Name (child 3)
Age (child 3)
Please provide names and ages of any additional children common to both parties.
Employment
Are you employed?
Please Select
Yes
No
If yes, name of employer:
Occupation:
Gross Monthly Income:
Do either of you own any businesses?
Please Select
Yes
No
If yes, nature of business:
Assets
Do you have joint bank accounts with your spouse?
Please Select
Yes
No
Do you own a home?
Please Select
Yes
No
Do you own additional real estate?
Please Select
Yes
No
Do you have investment or retirement accounts?
Please Select
Yes
No
Status
Have you already filed for divorce?
Please Select
Yes
No
If yes, date of filing:
-
Month
-
Day
Year
Date
Have you retained an attorney?
Please Select
Yes
No
If yes, name of attorney:
Do you have a pre-marital or post-marital agreement?
Please Select
Yes
No
Have you had marriage or family counseling?
Please Select
Yes
No
If yes, name of therapist:
Personal Information
The following questions may be sensitive and personal. Your responses are private and will not be shared with the other party.
Are you presently in therapy or counseling?
Please Select
Yes
No
If yes, name of therapist:
Has there been physical confrontation between you and your spouse?
*
Please Select
Yes
No
I'm not sure
If yes, information:
Is an Order of Protection or Restraining Order in place?
*
Please Select
Yes
No
I'm not sure
If yes, information:
Do you have any concerns about your safety with the other person?
*
Please Select
Yes
No
I'm not sure
If yes, information:
Has Child Protective Services ever been involved with the family regarding allegations of abuse or neglect of the children?
*
Please Select
Yes
No
I'm not sure
If yes, CPS or Juvenile Court case number:
If necessary, how would you prefer to be contacted about the information shared here?
*
Phone
Email
No Preference
How did you find out about us?
Please Select
Google
Bing
Yelp
Friend
Spouse
Therapist
Other
Name of therapist:
Do you want to mediate? Why or why not?
Submit
Should be Empty: